Abstract

Developmental disability in a growing child limits the
attainment of certain functions such as motor,
communication, perpetual and cognitive skills. Cerebral
Palsy (CP) is one such developmental disability that hinders
the movement and activities of daily living of the affected
child. In order to treat this disorder, several interventional
tools are available which has its own pros and cons.
Repetitive Transcranial magnetic stimulation (rTMS) is a
new noninvasive tool employed for the treatment of CP due
to its neuromodulatory effect that facilitates motor memory
formation, motor performance and motor learning in
individuals. In this report, a promising effect of rTMS
therapy is discussed wherein a wheelchair ridden patient
was able to crawl, kneel and move after two rounds of
treatment procedure.

Keywords

Introduction

Development of a growing child is an important process that
follows after birth such as smiling, babbling, waving, etc. that
ensures proper growth and future welfare of a child.
Development occurs in five domains: physical such as fine and
gross motor skill, communication such as receptive and
adaptive; language skill; perceptual skills such as senses of smell,
auditory visual and taste; social skill such as identification of
parent and adjustment in peer group and cognitive skills such as
understanding and meaningful interpretation of sensory
information [1]. All these domains are spontaneous
phenomenon in a normal growing child but the onset of each is
time dependent. If a child has not attained a certain
developmental skill by a certain age, then they are at increased
risk for a developmental disability [2]. Cerebral Palsy (CP) is one
such developmental disability that is found in children which
occurs due to birth complication or injury to the developing brain [3]. As a result of the brain injury, a child is not able to
perform activities of daily living and possesses limited
movement due to spasticity in the muscles. Muscle spasticity in
CP is a major cause that limits the physical functional movement
of the joints [4]. It is known that relieving muscle spasticity can
improve functional performances of the affected patients that
help achieve developmental milestone. Hence, a number of
interventional approaches are employed such as passive
stretching through physical therapy (PT), rhizotomy, muscle
relaxant medication, etc., to reduce muscle spasticity but none
of these treatment approaches were able to give desired results
in limited time span. In a quest to find an interventional tool for
CP patients we found that application of repetitive Transcranial
magnetic stimulation (rTMS) combined with PT demonstrated
some promising results towards gain in functional motor activity
[5,6] with reduction in muscle spasticity in CP patients [7]. The
case report presented here is one such amazing experience
while working with spastic CP children by employing rTMS.

Case Presentation

A 13 year old girl child was diagnosed as a case of spastic
quadriplegic cerebral palsy at an age of 2. According to her medical reports and positron emission tomography (PET) scan it
was found that her motor cortex area of the brain was severely
damaged. Surprisingly, her cognitive functions such as speech
and memory were not affected and she was able to understand,
communicate and speak normally. According to her birth history
she was an unplanned child, with birth weight less than 2.5 kg
and at the time of birth she delayed in crying, thus several birth
complications were observed by medical staff present during her
birth. Additionally, she also had a history of frequent seizures till
the age of three but it improved with medication and by 5 years
she was completely free from such attacks. Out of four sisters
and one brother, all siblings were normal; she was the only one
affected with CP. As reported by her sisters, she was able to walk
with support when she was 7 years old which must be a
combined effect of muscle relaxant medications such as
beclofenic sodium and botox along with routine physical therapy
that was provided to her. After the death of her mother, she was neglected and no proper treatment was given to her leading to
discontinuation of her medication and physical therapy. The
negligence pushed her towards the development of deformity in
knee flexion, contracture in lower limb bilaterally and elbow
flexion contracture in upper limb. She also developed swan neck
deformity in carpals and metacarpal bone and claw, hand
deformity in wrist joint. All these deformities and contractures
moved her towards physical dependency in performing any
physical movement independently.

She was brought to our centre for therapy at an age of 13 in
such a condition that she was not able to crawl or sit
independently. She had severe contractures and deformity at
elbow, knee and ankle joints bilaterally due to which she was
unable to perform any useful physical activity. The doctor at the
centre after knowing her history of medication and therapy
advised physical therapy for a month to observe changes in her
physical activity without any medication. There was mild change
in her muscle stiffness which was not satisfactory; then the
doctor advised rTMS along with PT. This choice of treatment
plan was made observing the benefits of rTMS on CP patients
for the past one year.

Prior to start of the rTMS therapy, her physical assessment
using modified Ashworth scale (MAS) for muscle spasticity, gross
motor function measure (GMFM) and gross motor function
classification system (GMFCS) for developmental milestone, preassessed
data was recorded. First round of rTMS therapy began
by stimulating her motor cortex area of the brain with frequency
of 10Hz and 2500 pulse train for 15 minutes daily for 20 days (5
days a week for 4 weeks) followed by PT of 30 minutes duration
daily for 20 days. After completion of 20 sessions, post
assessment of GMFM and GMFCS was performed and data
recorded. Second round of rTMS therapy was started after two
months of the previous therapy to evaluate the longevity of
effect of rTMS in this patient. Similar assessment and therapy
regime was performed in this round too. After completion of the
second round, the recorded data was analyzed to demonstrate
rTMS effect.

Results

The pre and post assessment scores (in %) of GMFM of both
the rounds is represented in Table 1. After completion of first
round of rTMS therapy, remarkable reduction in muscle
tightness in this patient was observed and the changes between
pre versus post GMFM score represented as functional motor
gain was found to be 20.60%.

In the first round 21.57%, 43.33% and 38.09% changes in pre
versus post GMFM score was observed in three GMFM domains
I, II and III respectively demonstrating that the patient was able
to freely perform rolling function and to a good extent sitting
and crawling. Additionally, total functional gain of 8.38% was
observed after completion of second round of therapy due to
improvement in GMFM domains II (15%), III (16.67%) and IV
(10.24%). Here it can be noted that just after two (2) months of
rTMS therapy combined with PT, this patient was able to regain
her motor function that was present when she was 7 years old.
The effect of rTMS on this patient was very encouraging as we could see a patient that came to the centre in an unmovable
condition can now crawl from place to place, kneel and even
walk few steps with the help of a support.

Discussion and Conclusion

TMS, is a noninvasive brain stimulation technique is proving to
be a promising tool for neurorehabilitation for various neurologic and psychiatric conditions due to its ability to
modulate cortical excitability of the motor cortex area of the
brain [8,9]. Additionally, it was demonstrated that TMS
stimulation of prefrontal and motor cortical areas gave rise to
trans-synaptic activation of subcortical circuits which is
responsible for motor activity [10] and in the management of
spasticity [11]. Furthermore, the use of TMS as research tool to
facilitate motor memory formation, motor performance, and
motor learning in healthy volunteers raised exciting hypothesis
for patients with neurologic and psychiatric disorders [12].
However, report on improvement of motor score and gait
pattern with high-frequency r-TMS combined with rehabilitation
therapy demonstrated its effectiveness in the management of
motor impairment and spasticity than rehabilitation therapy
alone [13] provides good evidences that rTMS through cortical
modulation leads to increase in the neuronal activities that
descends down the motor pathway for improving the muscle
functions. The rapid changes observed in this patient can be due
to all these effects of rTMS; where the therapy was able to
restore the motor memory that was once lost after the age of 7
and add more of functional activity in the patient as the therapy
continued. It is also worth reporting that this girl did not suffer
any seizures during and after rTMS therapy as reported by her
parents. Thus, it can be concluded that rTMS through its
neuromodulatory effect is an effective and safe treatment
approach for treating spastic CP patients by improving their
motor activity by reducing muscle spasticity and in facilitating
motor memory and learning functions.

Acknowledgement

This work is supported by funding received (Ref: SEED/TIDE/
007/2013) from the Technology Intervention for Disabled and
Elderly of the Department of Science and Technology (DST), Government of India, New Delhi. The authors also acknowledge
the support of all the staffs of UDAAN- for the differently abled,
Delhi. The authors are grateful to the child and her parents for
participating in this sponsored study.